Scratching the surface

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There’s much to be done to bring together substance misuse and mental health services so we can offer effective care for dual diagnosis, says Taf Kunorubwe

‘Before we can offer you a psychiatric assessment, you need to be abstinent for a minimum of two months.’

How often do service users receive such responses? My experience of working in mental health care, IAPT (the Improving Access to Psychological Therapies programme), substance treatment services and as a mindfulness teacher has shown me that this happens all too often. The most simplistic explanation of dual diagnosis is experiencing one of a range of mental health problems in conjunction with substance misuse. However I would caution against relying on a literal interpretation as multiple, complex and interdependent needs are often involved.

Unfortunately dual diagnosis has been a diagnosis of exclusion, with service users omitted from mental health services for substance misuse and substance treatment services unable to offer the level of support needed. This is despite widespread recognition that this client group has multiple needs, worse social outcomes and the need for holistic approaches. This is recognised by many studies and documents, including the Department of Health’s Dual diagnosis good practice guide; making every adult matter (a coalition of four national charities – DrugScope, Mind, Clinks and Homeless Link); the Dual Diagnosis Toolkit produced by Rethink and Turning Point; and IAPT’s Positive practice guide.

In the space of an article I could not adequately explore the various definitions, historical context, prevalence, service user experiences, or therapeutic interventions relating to dual diagnosis. Rather, I am aiming to share some helpful practice and to contribute to the discussion around how to support such service users.

Firstly, I cannot advocate training strongly enough; even basic awareness or assessment skills will benefit service users and boost workers’ competencies and confidence, and basic training should be available as part of everyone’s induction process. If this isn’t currently provided, you may wish to consider self-directed study or free e-learning packages such as the Dual diagnosis, making progress e-learning resource http://www.celecoventry.co.uk/projects/dualdiagnosis/.

For those regularly involved I would recommend further development via advanced practitioner training, which you may be able to access as part of your professional development plan, through bursaries or self-funding. 

Not only would training help workers to better support service users, it can also be a catalyst for culture change in services, shifting from attitudes such as ‘don’t ask don’t tell’, exclusion and non-compliance, towards non-judgemental positions, empathy and support. This will hopefully allow service users to be open and honest about their experiences and help engagement, allowing services to come to a shared understanding with them about recovery. Also, at a professional level, this more integrated culture should help to move us closer to a feeling of cohesion instead of ‘us and them’.

With non-judgemental, empathetic and supportive attitudes, we can embark on engaging more with service users. By this, I do not mean simply allowing access to services, but removing additional barriers and encouraging active engagement. Experience of this at the pre-assessment stage has been through outreach work, health promotion or working in conjunction with services that are first points of contact, such as food banks. During assessment we can actively engage by using therapeutic skills and entering into a conversation about how their substance use and mental health interrelate, psychoeducation and therapeutic treatment options – all of which will help to reach a joint decision and enable any subsequent work to be towards a joint view of recovery.

Once in treatment, I have often found a crossover of interventions, which aids engagement as we are addressing underlying processes. An example of this is in CBT sessions: we explore the impact that negative automatic thoughts have on depressed moods and how to challenge these. By the end of therapy, these coping strategies can effectively challenge negative automatic thoughts in relation to substance misuse. 

In instances where we possibly require further expertise, joint work can be helpful, and it doesn’t require superhuman effort to collaborate with mental health services. In my experience this can be as simple as attending team meetings, joint care planning, outreach, risk management and supervision. Not only does this aid active engagement with all the services involved, but it also means we have a shared culture of recovery, avoid repetition for clients, help to achieve integrated interventions and contribute to staff being supported. An example of this was through joint outreach with mental health services. We re-engaged with a high-risk service user and helped him to stabilise; whereas before when he disengaged, he deteriorated until he was detained under the Mental Health Act.

Not only does joint work benefit clients and aid engagement, but it is also helpful in developing an awareness of services, the treatment approaches available, referral routes, screening measures and the support they offer. I found this helpful when considering additional support for service users and enabling them to make an informed decision. For example what’s the difference between IAPT, psychotherapy, and psychosocial interventions? Does the IAPT employment retention service accept external referrals? Such information can be shared by open lines of communication developed through joint working.

Another useful practice is to consider the impact that both the mental health and substance misuse may have on a service user’s level of risk, so we can create a more holistic and comprehensive risk assessment and management plan. When assessing risk I often consider the following: risk to self, risk to others, risk from others, neglect, safeguarding, escalating substance use, deteriorating mental health and social functioning. For those interested in more information, there are good practice guides such as the Clinical risk management: a clinical tool and practitioner manual (2000) or Best practice in managing risk (2007).

Equally important is how relapse prevention is a crucial ingredient in recovery from either substance misuse or mental health problems, with a lack of integration meaning that one lapse often leads to another. As such, a holistic relapse prevention plan involving the service user and mental health services can be helpful. This plan can incorporate early warning signs, effective steps and smart goals, and should be followed by effective support from aftercare services.

This undercurrent of integrated care can effectively match the needs and goals of service users, avoiding the prescriptive approach that can overwhelm dual diagnosis service users and hamper engagement. By joint working, we can offer a range of support matching the care plan driven by the service user, regardless of service restrictions such as limits on the length of treatment.

Unfortunately, some services tend to be driven more by their own needs (and limitations) than the needs of service users. One recent example I came across was of a service user (who had significantly reduced her alcohol use) who had been encouraged into residential treatment for her drinking, after losing her accommodation because of noise complaints when she responded to voices. Soon after her admission we received concerns about her mental state and reports that other residents were frightened, and she was discharged as the rehab was ‘not equipped for dual diagnosis’.

Unfortunately, such experiences are all too common and illustrate some of the challenges that professionals face, which can contribute to compassion fatigue and burnout. As such, the provision of adequate levels of supervision and support is of utmost importance. Regrettably, my experience is that substance misuse services only provide limited supervision, which often focuses more on management issues such as targets and repercussions. Commissioners and managers need to be proactive in facilitating supervision, and professionals should feel comfortable requesting it. I often found it helpful to receive supervision or support through link work with other services, peer support or even using a buddy system. I cannot express enough gratitude to current and previous colleagues for providing these excellent, never-ending reserves of support, as I wouldn’t have coped without them.


My final suggestion relates to coping with the challenges professionals face, by practising self-care. I have personally found it useful to use the same interventions that I suggest to service users, such as cognitive restructuring, worry time, behavioural activation, transition from work to home, assertiveness, and practising mindfulness. For those interested in mindfulness, I recommend the three-minute breathing space. This can be summarised as – step one: becoming aware; step two: gathering and focusing attention; and step three: expanding attention. There are some useful free online resources that you can use for this.

In this article I have only been able to scratch the surface of the many helpful practices that can be introduced to support dual diagnosis service users and the professionals who work with them. My hope is to raise much-needed awareness, and share some helpful insights, alongside my passion for good practice. If nothing else, it is a call to arms to raise the profile of this challenging work and I look forward to hearing other perspectives. Some final words to managers and commissioners: please offer more support and strive to improve standards of care.  DDN

Taf Kunorubwe is a mindfulness teacher and a locum working at a CBT service within the NHS.